University College London Hospital Comprehensive Stroke Service

Clinical challenge
In 2020 we moved from one hospital site within our Trust to a new site and needed to rebuild our acute pathways and to develop partnerships within a new hospital system. This move led us to place new focus on the thrombolysis pathway and on our Door to Needle times for thrombolysis in acute ischaemic stroke and to create a new model for continuous case review and iterative  improvement in performance.

Solution
We rebuilt our thrombolysis pathway using our prior experience at the original hospital site

1. We centred our pathway around our thrombolysis nurse team so that the thrombolysis nurse for each call leads the patient flow through the pathway, ensuring that all safety guidelines are followed whilst facilitating fast progress to treatment decisions. The thrombolysis nurse also takes responsibility for time keeping, for leading the post-treatment debrief and for ensuring that process metrics and learning from each case are recorded.
2. We invited one of our senior stroke nurse practitioners to lead on the weekly case review meeting that focuses on relevant learning from all cases treated in more than 30 minutes or less than 20 minutes post arrival at the hospital. We ensure that this meeting is well attended by the wider stakeholder group (nurses, junior and senior doctors, radiographers and porter representatives) and that the learning is disseminated across all the teams.
3. The stroke nurse practitioner team lead the monthly simulation programme which is mandatory for all new doctor starters on our service. This simulation programme demonstrates our pathway to the new team but also makes visible our focus on the active partnership between doctor and nurse through the course of each clinical case.
4. We meet at the beginning of each shift to identify who has each role in the thrombolysis team and to check all are familiar with the pathway and the process.
5. We make visible each month the highest performing team, with the name of the relevant nurses, doctors, radiographers (and for thrombectomy radiologists and anaesthetists) flagged to the entire service together with the time achieved. This brings together the wider team and creates a healthy spirit of motivation towards fast times. We support this process with certificates of achievement and some small gifts of thanks as tangible reward for hard work.

In addition to these improvements on our original pathway our stroke nurses participate in all the video pre-assessment triages planned for conveyance to our hospital so that our team are aware and have planned provisional actions for all cases potentially for thrombolysis (and thrombectomy) even before arrival.

Impact
Our model keeps visible to the team our focus on safety and efficiency but also our drive to keep improving. The model also has helped us to bring the wider team together most visibly through the daily meetings at the start of the shift. Finally the model has engaged and empowered the stroke nurse team to actively manage the pathway in real time if delays begin to appear. The monthly review and publishing of excellent times boosts teams spirits and allows for a healthy competition within the team and encourages knowledge and practice sharing and leads to skill development across the whole team.

Reflection
We had been running thrombolysis pathways since 2010 but our service change in 2020 led to a re-structuring of our pathway, informed by our previous experience. In the new pathway we have placed our stroke nurses at the centre, have optimised our model for building team working through collaboration and have made constantly visible to all the involved teams, our successes and the team members who have achieved together these results. In addition, our team have found huge benefit from the opportunity provided by pre-hospital video review.